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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1393_Библиотеки_им_академика_М_И_Перельмана.pdf
4 Hemorrhoids 63
Fig. 4.1 Open (Milligan–Morgan) hemorrhoidectomy. a External hemorrhoids grasped with
forceps and retracted outward. b Internal hemorrhoids grasped with forceps and retracted outward
with external hemorrhoids. c External skin and hemorrhoid excised with scissors. d Suture placed
through proximal internal hemorrhoid and vascular bundle. e Ligature tied. f Tissue distal to
ligature is excised. Insert depicts completed three bundle hemorrhoidectomy
64 J. Cintron et al.
Fig. 4.2 Modified Ferguson excisional hemorrhoidectomy. a Double elliptical incision made in
mucosa and anoderm around hemorrhoidal bundle with a scalpel. b The hemorrhoid dissection is
carefully continued cephalad by dissecting the sphincter away from the hemorrhoid. c After
dissection of the hemorrhoid to its pedicle, it is either clamped, secured, or excised. The pedicle is
suture ligated. d The wound is closed with a running stitch. Excessive traction on the suture is
avoided to prevent forming dog ears or displacing the anoderm caudally
Perianal Infiltration of Local Anesthetics
Probably one of the most important pillars in the mul timodal approach is the
intraoperative administration of local analgesics. The use of locally infiltrated
anesthetics in conjunction with intravenous sedation is safe and may even have
fewer complications than other anesthetic techniques for excisional hemorrhoidectomy. This technique has been shown to be the most cost effective anesthetic technique when compared to spinal anesthesia an d general anesthesia [4].
This randomized clinical trial compared these three anesthetic techniques in 93
patients undergoing ambulatory anorectal surgery. The local anesthetic infiltration
consisted of a mixture of 15 mL of 2% lidocaine and 15 mL of 0.5% bupivacaine
4 Hemorrhoids 65
Fig. 4.3 Whitehead hemorrhoidectomy. a Suture placed through proximal internal hemorrhoid
for orientation. Excision started at dentate line and continued to proximal bundle. b Internal
hemorrhoidal tissue excised above ligated bundle. c Vascular tissue excised from underside of
elevated anoderm. d End of anoderm reapproximated with sutures to original location of dentate
line. (E) Completed procedure
with 1:200,000 of epinephrine. The intravenous sedation consisted of propofol.
There was a 30–50% cost savings over the other anesthetic techniques in the
ambulatory setting. In addition to the increased cost savings with this technique,
there was also no difference in postoperative side effects and unanticipated hospitalizations when utilizing local perianal infiltration . The need for pain medication
was also less in comparison to general anesthesia. An anal block is perfor med by
66 J. Cintron et al.
infiltrating circumferentially either in a field block subcutaneously and submucosally or by infiltrating into the intersphincteric groove in a four- or eight-quadrant
manner. Additionally, local infiltration to the proposed site of excision is needed in
order to ensure adequate anesthesia during the case. Since pain is the most common
reason for delaying discharge after ambulatory surgery, significant attention must
be given to good analgesia for effective postsurgical pain management. Most of
these agents are short acting however, and can block noxious stimuli and pain
intensity for at most 8–12 h after which the patient must take other analgesics to
control pain.
Liposomal Bupivacaine
Approved by the FDA in 2011, Exparel®is a liposome injection of the amide local
anesthetic bupivacaine encapsulated in a proprietary DepoFoam
nology that is infiltrated into the local site for postoperative analgesia. The Depo-
®
Foam
consists of multivesicular liposomes that encapsulate the bupivacaine and
®
delivery tech-
release it over an approximately 96-h period. These properties are beneficial in
prolonging the time to first narcotic use and in decreasing overall narcotic use. The
drug is infiltrated locally at the end of surgery. Gorfine et al. [5] published a
randomized multicenter, double-blind placebo controlled trial in 189 adults
undergoing excisional hemorrhoidectomy (2- or 3-column). Those patients who
received a bupivacaine liposome injectable suspension had a 30% statistically
significant reduction in pain scores at 72 h. In addition, this led to a significant
reduction in opioid consumption. Haas et al. reported a randomized clinical trial
using liposomal bupivacaine for post-hemorrhoidectomy pain management compared to standard bupivacaine HCL [6]. They found that the liposomal bupivacaine
significantly reduced postsurgical pain and opioid consumption in comparison to
bupivacaine HCL. This in turn led to decreased opioid-related adverse events.
Of note, the injection of bupivacaine liposomal injectable suspension should not
be admixed with lidocaine or other non-bupivacaine-based local anesthetics, which
can lead to the immediate release of bupivacaine from the suspension.
Catheter Delivery Systems
These pumps were developed to provide a continuous infusion of nonnarcotic pain
relief in the form of local anesthetics directly to or near the surgical site through
specially designed catheters. This delivery method can provide patients with days of
targeted pain relief after surgery thereby minimizing narcotic usage and the side
effects that go along with increased narcotic usage such as nausea, emesis, constipation, and over sedation. In theory, the use of catheter delivery systems, which
provide a continuous administration of local anesthetics to the site of surgery
through a locally placed catheter, seems intuitive. However, this has been significantly limited by difficulty in maintaining correct catheter position, the cost of the
4 Hemorrhoids 67
delivery device, and the resources needed to manage patients in the outpatient
setting. These catheter delivery systems (STA cath
®
, On-Q®) are not used widely
for excisional hemorrhoidectomy for the reasons listed above.
NSAIDS and Cox-2 Inhibitors
Nonsteroidal anti-inflammatory drugs (NSAIDS) are peripherally acting analgesics
utilized worldwide. These drugs provide pain relief and an alternative to
opioid-based analgesia. They play a key role in the multimodal approach to pain
relief in the perioperative setting providing analgesic, anti-inflammatory, and
antipyretic benefits. The use of NSAIDS in the perioperative period has been shown
to provide improved analgesia, lower rates of urinary retention, and decreased
narcotic usage [7–9]. Additionally, it is not associated with excessive sedation,
respiratory depression, or cognitive dysfunction. This drug is indicated for the
management of moderate to moderately severe postsurgical pain. NSAIDS can be
delivered orally, transdermally, intramuscularly, intravenously, and through direct
local infiltration at the surgical site. Ketoralac tromethamine was the first injectable
NSAID approved for use in the USA. The combined duration of oral, intramuscular, and intravenous administration should not exceed 5 days. When utilized in a
multimodal fashion a 30 mg loading dose followed by 15–30 mg doses every 6 h
can be a potent adjunct and opioid sparing modality to control postoperative pain.
However, analgesic effects must be balanced and weighed against the potential for
adverse effects especially GI bleeding, platelet dysfunction, and renal failure [7, 8].
Another injectable NSAID formulation approved in the USA in 2006 was
injectable ibuprofen (Caldolor
moderate pain by itself or as an adjunct to opioid analgesics (Ibuprofen Injection
(Caldolor
®
). Nashville, TN: Cumberland Pharmaceuticals, Inc. [10]. Recommended
dosing for ibuprofen injection are 800 mg every 6 h with a maximum dose of
3200 mg over a 24 h period. Patients weighing less than 50 kg and elder ly patients
may achieve effective analgesia with 400 mg doses. Its lower selectivity for Cox-1
isoenzymes in comparison to Ketoralac may reduce the risk of adverse side effects
such as GI bleeding or platelet dysfunction. Unlike Ketoralac, this drug should be
diluted with 250 mL of sterile saline or lactated Ringer’s solution and infused
slowly over 7–15 min in order to achieve maximal plasma concentrations more
rapidly and at the site of tissue injury.
Cox-2 inhibitors were developed to improve GI safety while providing effective
analgesia. Approved by the FDA in 1998, the only Cox-2 inhibitor available for
perioperative pain management is celecoxib (Celebrex
is more selective for the Cox-2 isoenzyme, which is induced following tissue injury.
Unfortunately, other Cox-2 inhibitors were withdrawn from the US market and the
FDA mandated a black box warning for celecoxib with respect to its risks regarding
cardiovascular and cerebrovascular thrombosis with long-term use.
®
). This medication can be used to treat mild to
®
). This subclass of NSAIDS
68 J. Cintron et al.
Acetaminophen
This is a centrally acting analgesic for mild to moderate acute as well as chronic
pain that is one of the most widely administered over the counter analgesics. Since
it does not act peripherally it has no anti-inflammatory effects locally at the site of
surgery. Modes of administration include oral, rectal, and intravenous. It has been
shown to significantly reduce postsurgical pain versus placeb o [11]. Additionally,
acetaminophen lacks the adverse side effects of NSAIDS and opioids. The intravenous formulation (Ofirmev
In addition to its antipyretic benefits, it is indicated for the treatment of mild to
moderate pain by itself or as an adjunct to opioid analgesics in the treatment of
moderate to severe pain. The touted benefits over the oral or rectal formulations are
a higher analgesic efficacy, a higher maximum plasma concentration, and a more
rapid onset of action. The medication comes in a 1000 mg solution that should be
infused over a 15-min period every 4–6 h not to exceed 4 g/day in adults less than
70 years of age. Dosing should be adjusted for children, adolescents, and the
elderly. There are some data to suggest that the analgesic effectiveness of intravenous acetaminophen is enhanced when administered prior to making the surgical
incision although this was in patients undergoing abdominal hysterectomy and not
excisional hemorrhoidectomy [12]. Because of acetaminophen’s narrow therapeutic
window great care should be taken to adhere to recommended dosing by the
manufacturer in order to minimize potential hepatotoxicity. Additionally, acetaminophen should not be used in patients with severe hepatic impairment or severe
active liver disease.
®
) gained FDA approval in the United States in 2010.
Metronidazole
Orally administered metronidazole has been shown to improve postoperative pain
after excisional hemorrhoidectomy [13]. Published results, however, have been
somewhat variable and can either support or not support the use of metronidazole
[14, 15].
Glyceryl-Tri-Nitrate (GTN)
Nitroglycerin ointment has been studied looking at its analgesic efficacy, its effect
on wound healing, and its adverse effects with respect to headache. Glyceryl
trinitrate has been shown to decrease muscle spasm and increase anodermal blood
flow. A meta-analysis looking at 333 patients from 5 randomized trials demonstrated analgesic efficacy on days three and seven compared to placebo [16].
Additionally, wound healing was reported to be better at 3 weeks compared to
placebo and the side effect of headache was not statistically increased over placebo.
4 Hemorrhoids 69
Another meta-analysis of 12 randomized controlled trials by Liu and colleagues
looked at a total of 1095 patients. That meta-analysis found that there was a
significant pain reduction on days 1, 3, 7, and 14. There also seemed to be a benefit
with respect to improved wound healing three weeks postoperatively but this came
at a cost of increased headache [17].
Joshi and Neugebauer reported a study on behalf of the PROSPECT Collaboration working group evaluating the available literature on the management of pain
after hemorrhoid surgery [18]. The collaborative group was formulated to provide
evidence-based recommendations for specific surgical procedures. Of 207 randomized studies identified, only 106 met inclusion criteria and of these 41 were
excluded leaving a total of 65 studies for evaluation. Although quantitative analyses
were not performed, the conclusion was that local anesthetic infiltration either as a
sole technique or in conjunction with a multimodal approach to pain (NSAIDS,
Acetaminophen, Opiates) is recommended in the management of pain after hemorrhoidectomy. The following algor ithm can be utilized in the management of
postoperative pain after excisional hemorrhoidectomy (Fig. 4.4) (Pain management
algorithm).
Fig. 4.4 Pain management algorithm for excisional hemorrhoidectomy
70 J. Cintron et al.
Urinary Retention
Postoperative urinary retention after excisional hemorrhoidectomy is the most
frequent complication after pain. This is especially evident after multiple-quadrant
excisions or the performance of other concomitant anorectal procedures performed
at the time of excisional hemorrhoidectomy. A number of studies have shown that
limiting perioperative fluids to less than 1000 mL can lower the incidence of urinary retention from approximately 20% to less than 10% [19, 20]. Bailey lowered
the incidence of urinary catheterization from 14.9 to 3.5% with fluid restriction
[19]. Additionally, multimodal analgesia has been shown to decrease urinary
retention from 25 to 8% [21]. Toyonaga et al. found that female sex, presence of
preoperative urinary symptoms, diabetes mellitus, need for postoperative analgesics, and more than three hemorrhoids resected were independent risk factors for
urinary retention as assessed by multivariate analysis [21]. The most recent practice
parameters published by the American Society of Colon and Rectal Surgeons gives
a strong recommendation with level 1B evidence stating that “urinary retention after
ambulatory surgery may be reduced by limiting perioperative fluid intake.” [22]
Since the vast majority of hemorrhoidectomies are performed on an ambulatory
basis it is not very practical to mandate voiding prior to discharge. Patients are
encouraged to minimize fluid intake until voiding. Warm sitz baths or warm
showers the following day usually promote voiding.
Postoperative Hemorrhage
Massive hemorrhage after excisional hemorrhoidectomy requiring operative treatment occurs in less than 1–2% of patients. Hemorrhage occurs either early (immediate in PACU or within 48 h) or late (72 h or greater). Although it is usually not
difficult to identify bleeding internally, it can be potent ially masked if there is an
anal pack in place and some surgeons advocate not placing an anal pack after
hemorrhoidectomy for this reason.
Early Hemorrhage
Hemorrhage in the early postoperative period is almost always secondary to a
technical issue likely from inadequate ligation of the internal hemorrhoid pedicle.
Although bleeding from the external portion of the wound is unusual, it can occur
and can potentially be managed at the bedside in the PACU. Bleeding from the
external wound may be managed with simple injection of 1% lidocaine with
1:100,000 epinephrine. This may control the bleeding alone and at the very least
allows the surgeon the ability to assess the outer wound carefully. Occasionally,
suture ligation of a bleeding point on the external skin may be needed. If there is
severe bleeding from the a nal canal while the patient is in the post anesthesia care
unit (PACU) or within 48 h they should be brought back to the operating room
immediately. This will allow optimal visualization and management with suture
ligation.
4 Hemorrhoids 71
Late or Delayed Hemorrhage
Late or delayed hemorrhage can occur up to several weeks after excisional hemorrhoidectomy although the majority occurs within the first week. The delayed
hemorrhage frequently requires admission to the hospital for observation and
management. Delayed hemorrhage is usually due to bleeding from the sloughed
hemorrhoidectomy wound where there is a granulating tissue base possibly with an
exposed vessel. The incidence of late bleeding is similar in open Milligan–Morgan
hemorrhoidectomies versus closed Ferguson hemorrhoidectomies [23]. Delayed
hemorrhage can be managed through a variety of treatments. Once the patient is
resuscitated in the emergency department, an assessment is made to determine the
extent of bleeding through a thorough history and physical examination. If the
patient is hemodynamically unstable despite resuscitation then they should be
brought to the operating room immediately for an examination under anesthesia and
possible suture ligation. If the patient is stable, then an attempt can be made to
perform rectal tap wat er irrigation with a large three-way foley catheter. This
usually does not require anesthetics or narcotics but can be used on a selective
basis. If fresh blood is persistent throughout the rectal irrigation then the patient
should be brought to the operating room for an examination under anesthesia. If the
rectal irrigation becomes clear then the patient can be admitted for close observation. Chen et al. performed a prospective study comparing rectal irrigation with
immediate examination under anesthesia. They found that rectal irrigation was well
tolerated and bleeding stopped in 88% of patients. In comparison to surgery patients
undergoing rectal irrigation had a higher satisfaction, lower length of stay and more
cost effective treatment [24].
Another minimally invasive approach is proctoscopic or anoscopic inspection
followed by injection of 1% lidocaine with 1:100,000 epinephrine. This may
require the use of local anesthesia and narcotics for patient tolerance. Additionally,
good lighting is essential for appropriate visualization [25].
Anal packing has been described with a variety of materials including Su rgicel,
and gelfoam soaked with thrombin or epinephrine. This usually requires anesthesia
and narcotics for patient tolerance and may lead to other complications such urinary
retention [26]. An alternative to packing is Foley catheter tamponade of the
bleeding. Once the catheter is inserted the balloon is inflated with 20–40 mL of
fluid and placed on gentle traction. The balloon can then be deflated and removed
within 24 h. This techni que can also be utilized as a temporizing procedu re prior to
going to the operating room if it is not immediately available [27, 28]. Lastly, in
patients with significant ongoing bleeding, suture ligation in the operating room
provides the best means for a thorough and painless examination so that suture
ligation can be performed.
Infection
Although the rate of bacteremia has been reported to be as high as 8.5% following
sigmoidoscopic examination, the incidence of local infectious complications and or
systemic sepsis is surprisingly low following excisional hemorrhoidectomy. This
has been attributed in part to the excellent blood supply of the anorectal region as
72 J. Cintron et al.
well as effective clearance of portal bacteremia by the reticuloendothe lial system of
the liver [29]. There is definitely a paucity of reported wound infections following
hemorrhoidectomy. The reported rate of local infection following excisional
hemorrhoidectomy in most cases is less than 1–2%. In a report by Bouchard et al. in
over 600 patients undergoing hemor rhoidectomy the incidence of local infection
was 1.4% [30]. Chen et al. reported 1 infection in 666 patients undergoing excisional hemorrhoidectomy with the LigaSure device [31]. Qarabaki et al. reported
zero wound infections in a comparative study looking at 688 patients undergoing
either circumferential excisional hemorrhoidectomy versus three-quadrant Ferguson
hemorrhoidectomy [32].
Anal Stenosis
Anal stenosis following excisional hemorrhoidectomy is usually a preventable
complication that results from excessive excision of perianal skin and or anoderm.
Its incidence is typically less than 5% but has been reported as high as 10%. The
best treatment for anal stenosis is prevention. If adequate skin bridges and anoderm
are preserved during excisional hemorrhoidectomy, the risk of anal stenosis will be
decreased. Excisional hemorrhoidectomy is best performed with a large
Hill-Ferguson retractor in place during the entire procedure. If disease is circumferentially extensive then you are better off leaving enough skin/anoderm bridges
in situ even though the patient may complain about some residual disease. This can
be taken care of at a subsequent operation if needed once there is complete healing
of the initial wounds. Although the surgeon has the option of performing more
extensive excision with a concomitant anoplasty, it is my preference to leave sufficient skin bridges and anoderm in situ to avoid postoperative anal stenosis. The
timeline for presentation of anal stenosis may be anywhere from weeks to several
months after excisional hemorrhoidectomy [33]. Medical and or surgical treatment
should be tailored to the severity of anal stenosis. Patients usually report painful or
difficult bowel movements, rectal bleeding, and or narrow caliber stools. Visual
inspection and attempted digital rectal examination usually establishes the diagnosis
of anal stenosis. However, some patients may require examination under anesthesia
in order to make an adequate assessment. If the etiology of the stenosis is unclear
then the patient should undergo endoscopy to rule out malignancy and or inflammatory bowel disease. Crohn ’ s disease must also be in the differential diagnosis.
Stenoses can be classified as either mild, moderate or severe [34]. A mild stenosis is
characterized by the ability to perform a digital rectal examination on the patient or
to be able to insert a medium Hill-Ferguson retractor into the anus without forceful
dilatation. A moderate stenosis requires forceful dilatation in order to perform a
digital rectal examination or to insert a medium Hill-Ferguson retractor. A severe
stenosis is defined as one in which the 5th digit or a small Hill-Ferguson retractor
can only be inser ted with forceful dilatation. Stenoses can also be classified as to
their level of involvement as low, middle, and high [35]. Low involves at least
0.5 cm distal to the dentate line, middle 0.5 cm distal and proximal to the dentate